Hospital aims for zero patient harm
Two hospitals in Boston are taking the lead in patient safety by pledging to eliminate all preventable patient harm within four years, a goal that some patient safety experts applaud, but which others say is not a realistic goal.
Beth Israel Deaconess Medical Center (BIDMC) and Beth Israel Deaconess Hospital Needham (BID Needham) recently announced the unprecedented steps to commit each hospital to attain specific patient safety and satisfaction goals that would establish a new standard of care at each facility. The boards of both institutions have approved goals that call for the "elimination of all preventable harm to patients" and a "consistently excellent patient experience" by Jan. 1, 2012.
BIDMC's also pledged full transparency by saying data on progress toward those goals will be reported publicly each quarter on its web site at www.bidmc.harvard.edu/thefacts. That site currently charts how BIDMC measures up with hospitalwide programs, such as reducing infections and patient satisfaction, as well as in specific areas of clinical care.
Kenneth Sands, MD, senior vice president of health care quality at BIDMC, says the hospital leaders acknowledge that the goal of reducing all preventable harm is ambitious, but they believe it is attainable. Harm is defined as any action that causes hospitalization or a longer hospital stay; permanent injury or disease progression; or patient death. The boards also instructed the hospitals to "continually monitor all preventable and nonpreventable occurrences of harm, and continuously improve our systems.
"We feel that focusing on these categories will give us the greatest opportunity to achieve a meaningful and sustainable reduction of harm," Sands says.
Quality goal also is high
As for the goal of giving patients a "consistently excellent patient experience," Sands says that will be measured by being in the top 2% of hospitals for patient satisfaction in the country, based on national survey responses to their "willingness to recommend" the hospital to their friends and family. BIDMC reports that it currently performs in the top 10%-15% range based on all hospitals nationally in the widely used Press Ganey survey, while BID-Needham reports that it is in the top 30% of national peer group hospitals.
Exactly how the hospitals will strive for these goals still is unknown. Risk managers will no doubt be curious to see what strategies they employ and how successful they are, but for now BIDMC and BID-Needham officials only say they are devising programs for achieving the goals and determine the metrics against which performance will be measured. Beginning in the spring of this year, the agendas of the board meetings will change to include systematic reviews of progress toward the goals on a quarterly basis, and the metrics will be posted on the hospitals' public web site, according to a BIDMC statement.
Patient safety experts are debating whether zero tolerance is reasonable. Donald Berwick, MD, president and CEO of the Institute for Healthcare Improvement (IHI) in Cambridge, MA, and a leading authority on patient safety, says he sees no problem with the ambitious goal.
"All mature safety systems in other industries have that mentality, that zero is the only correct goal," Berwick says. "No airline says they're only going to have one crash every 10 years. They say they're going to have zero. So it's perfectly fine as a cultural leadership move to strive for zero."
Technically possible with some errors
Berwick says the goal can be inspiring and help change the culture of the institution. And he says it is technically possible, at least with regard to some specific types of preventable patient harm. Some hospitals are already achieving zero or near-zero patient harm from central line infections, ventilator pneumonia, and pressure ulcers, he says.
"Beth Israel's stretch is enormous here, no doubt about it. They're really raising the bar," Berwick says. "I think it's a very wise goal. I hope they get to zero, but if they only get to 90% of the errors eliminated, that's still cause for champagne."
Not everyone agrees with that point. Eric Thomas, MD, associate professor in general internal medicine at The University of Texas Medical School at Houston, is a leading researcher in patient safety, and he says the BIDMC plan gives him pause. Getting to 90% may only demoralize employees who were told that 100% was the measure of success, he says.
"It doesn't seem like a possible thing to attain, particularly with what we know about human decision making and human performance in stressful situations. People make mistakes, and those mistakes lead to what we would consider preventable harm to patients," he says. "You can't get rid of that."
A better strategy may be to concentrate on learning from each incident of preventable harm, Thomas suggests. Thomas says the zero-harm goal will be more feasible if the plan is to focus on very specific types of preventable harm that can be controlled in concrete ways. But a broad goal of eliminating all preventable patient harm in four years may just be a recipe for failure, he says. He also worries that a zero goal will have unintended consequences.
"The message it sends to staff is that they're not supposed to make mistakes, and than can lead them to cover them up or not report them," he says. "Or you can end up redefining them so that they're not really preventable errors. If you tell people that they just can't make these errors, ever, then they may find a way to avoid telling you."
Sources
For more information on the Boston patient safety initiatives, contact:
- Donald Berwick, MD, President, Institute for Healthcare Improvement, Cambridge, MA. Telephone: (617) 301-4800.
- Eric Thomas, MD, Associate Professor in General Internal Medicine, The University of Texas Medical School at Houston. Telephone: (713) 500-6702. E-mail: [email protected].
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